Elite Term Life Insurance Quote

Coverage Amount: (Minimum $100,000)	$	Height:
Weight:	lbs.	Gender:
Date of birth:

Please answer the following questions to help us better estimate your premium. Actual premiums will vary based on the results of our underwriting process. This is not an application for insurance and will not be used as part of the underwriting process.

Lifestyle profile
Have you ever been convicted of a DWI (Driving While Intoxicated) or DUI (Driving Under the Influence)?
Have you had more than two moving violations in the last two years?
Have you ever had a problem with or been treated for drug or alcohol abuse?
When was the last time you used tobacco or nicotine products?
Do you work in a hazardous occupation?
Do you engage in any hazardous activities or sports?
Do you currently fly or intend to fly as a private pilot?

Medical history
Have you ever been treated for or been told that you have high cholesterol?
Have you ever been treated for or been told that you have high blood pressure?

Indicate each medical condition that applies to or has applied to you:
Asthma	Anxiety	Anemia	Allergies
Sleep Apnea	Hypothyroid	Reflux	Epilepsy
Chronic bronchitis Emphysema	Gastric/peptic ulcer	Hypertension	Depression (last two years)
Mental illness (treatment in last two years)	Diabetes	Cancer	Heart Disease
Check this box if you have family history of cardiovascular deaths or multiple cancer deaths prior to age 60 in parents or siblings.